Mihaela Vlad, Ioana Golu & Ioana Zosin

Victor Babes University of Medicine and Pharmacy, Timisoara, Romania.

Graves orbitopathy (GO) represents ophthalmic symptoms that affect, usually, patients with Graves disease. Rarely, it can occur in subjects without thyroid dysfunction or with hypothyroidism (25% of the cases).

In this report we present a rare case with unilateral GO and initial euthyroidism, which progressed to hypothyroidism, due to an autoimmune atrophic thyroiditis.

A 39-year-old woman, long-term smoker, was referred to our department for investigations due to right eye exophthalmia. On admittance the patient didnt show symptoms or signs typical for hypo- or hyperthyroidism. Laboratory results indicated normal TSH and FT4. Immunological determinations revealed elevated titers of anti-TSH receptor antibodies (7.7 IU/l, normal range 0-1 IU/l) and anti-thyroid peroxidase antibodies (917.3 UI/ml, normal range 050 UI/ml). Thyroid ultrasonography presented a normal thyroid volume with decreased echogenicity of the parenchyma, without nodules. Magnetic resonance image of the orbits showed right exophthalmia due to thickening of all the orbital muscles and of the adipose tissue, allowing us to exclude a mass that could induce the protrusion of the right eye.

The CAS score was 3 and NOSPECS index  4. A moderate active form of unilateral thyroid orbitopathy was diagnosed and methylprednisolone pulse therapy was given.

Despite the glucocorticoid therapy, nine months later the patient was hospitalized again due to progression of orbitopathy. Symptoms and signs of hypothyroidism were detected and hormonal determinations revealed high TSH (68.8 μUI/ml, normal range 0.494.67) and low FT4 (<0.4 ng/dl, normal range 0.711.85). Levothyroxine therapy was started and methylprednisolone pulse therapy was given, with partial remission of the ophthalmic symptoms.

Conclusions: This report describe a rare case with unilateral GO and atrophic autoimmune thyroiditis. The unexpected evolution to hypothyroidism has worsened the exophthalmia. The correct detection and treatment of the thyroid insufficiency resulted in a significant improvement of the clinical state.